On Friday 11 August 1978, Janet Parker was getting ready for work when her head started to pound. She thought she was coming down with flu: she felt sore all over. But she had lots to do that day, so her husband, Joseph, drove her to Birmingham University, where she worked as a photographer in the medical school’s anatomy department.
At 40, Parker’s life was steady. She and Joseph, a Post Office telecoms engineer, lived in a modest house in Kings Norton, a quiet suburb of Birmingham. They had two dogs, and were close to her parents, who lived nearby. Parker was an only child, and her father worked for a small family firm in Birmingham’s jewellery quarter. She got into a grammar school and stayed on beyond 16, unlike many children from her background. Her first job was to photograph crime scenes for the West Midlands police, being summoned, often in the middle of the night, to photograph the aftermath of brutal murders, bodies with alarming injuries and blood-spattered walls.
In 1976, aged 37, she got a job with more regular hours, as a photographer in the medical school on the leafy campus in Edgbaston. Her job was to photograph tissue sections on slides, and take pictures for academic materials. Occasionally, she would photograph primates; the medical school had a large animal colony at the time, with macaques, baboons and marmosets, as well as rabbits, rats and mice.
There was no staff canteen; instead, a group of employees, mostly women, met in a bay off a corridor in the anatomy department. They were known as the “coffee club”. “We’d meet up mid-morning, lunchtime and mid-afternoon,” says Glenda Miller, 70, then a research technician. “We’d knit and chat. Sometimes, Janet would study.” She was taking an Open University degree.
On Monday 14 August, Parker didn’t turn up. On Wednesday, Miller rang to see how she was. By now she had developed red spots on her chest, limbs and face. Parker’s GP had made the tentative diagnosis of chickenpox after a home visit, although her mother was sceptical as she had nursed Parker through the illness as a child. The doctor prescribed an antibiotic for cystitis and a painkiller. “Janet sounded tired,” Miller continues. “Then she said, ‘I’ve never felt so ill in my life.’ And that was it. I never heard any more.” Just over a week later, on Thursday 24 August, Parker was diagnosed with smallpox, a lethal, highly contagious virus that had been eradicated with great fanfare only a year before.
The diagnosis triggered a public health emergency in Birmingham, then home to just over a million people, was debated in parliament and worried World Health Organization officials in Geneva. The mystery of how Janet caught smallpox, and its tragic consequences, have since been the subject of two investigations, and most recently a book, The Last Days Of Smallpox, by Mark Pallen, a professor of microbial genomics at the University of East Anglia. Pallen has his theories, but exactly how Parker became infected has never been fully explained.
Now, the case has taken on a new resonance. The terror of a deadly virus, a city’s scramble to stave off catastrophe, the emotional toll affecting those on the frontline, all the lives changed for ever – it could be a description of our current crisis. Does what happened in Birmingham more than 40 years ago offer lessons for today’s battle with Covid-19?
Smallpox kills by disabling the immune system. The first symptoms are a high fever, headache, backache and vomiting. Then the rash appears and slowly spreads. It starts in the mouth, lightly covers the trunk, but the greatest devastation is to the extremities – face, arms, legs, hands and feet. The spots start out flat and red, ballooning into large, fluid-filled pustules. Those who survive are often permanently scarred. Some are left blind.
For thousands of years, smallpox had been a fact of life, killing millions. The Crusaders spread it through Europe, and European colonists infected Native Americans, transforming the continent for ever.
Smallpox is a poxvirus, a group of brick- or oval-shaped viruses that can infect animals and humans; others include myxomatosis and cowpox (chickenpox is not caused by a poxvirus, but a herpes virus). Like Covid-19, smallpox is thought to have jumped from animals to humans. It is spread through coughs and sneezes, and lives on surfaces, particularly the bedding and clothing of those with the disease, as sores leak the virus, even when crusted over.
Smallpox is mild for some, deadly for others. Roughly 30% of patients die (compared with around 1% for Covid-19) and in contrast to the seeming invulnerability of most children to Covid-19, mortality is high for babies and young children. Then, as now, health experts pinned their hopes on a vaccine.
In 1967, there were still 15m cases in 44 countries, from Nepal to Brazil to Afghanistan. Some of the most heavily infected countries were also some of the world’s poorest. That year, the WHO launched the Intensified Smallpox Eradication Programme, a 10-year mass vaccination effort, involving 150,000 field workers in about 50 countries. At first, in an echo of Covid-19, the aim was to achieve “herd immunity” – though rather than relying on people getting the disease and becoming immune as a result, the tactic was mass vaccination. This approach was not very successful, particularly in densely populated countries such as Bangladesh, India and Pakistan, as the virus could still be transmitted even when 95% of the population was vaccinated.
From 1969 onwards, the WHO recommended “ring vaccination”: tracing, isolating and immunising contacts. The idea was to wall off the disease with protective rings of immune individuals. The strategy capitalised on the relatively slow spread of the disease – smallpox has an incubation period of about 12 days when the patient is not infectious. This meant that once a case was identified there was time to act. And while the smallpox vaccine works best if given before any exposure to the disease, having the jab up to three days after exposure offers some protection.
Every conceivable method of transport was used to get the vaccine to its targets: Jeeps, motorcycles, bicycles, mules, even elephants. Doctors swam across rivers with vaccine equipment on their heads. By October 1977, there was thought to be only one case remaining: Ali Maow Maalin, 23, from Merca, a port in Somalia. Although Maalin had worked as a vaccinator in the smallpox eradication programme, and then as a cook in a hospital, he had never been vaccinated himself. He picked up the virus after getting in a car carrying two small children with smallpox, to direct the driver to an isolation camp.
Within eight days of Maalin’s smallpox being confirmed, everyone who lived in the 792 homes in his neighbourhood was vaccinated, as well as all those leaving and entering the city. In all, 54,777 people were vaccinated over two weeks. Transmission ceased. Smallpox was eradicated.
But the virus lived on in laboratories around the world. Established in 1779, Birmingham medical school is one of the oldest in the country. Janet Parker’s photographic studio and darkroom were on the first floor. On the floor below was the department of medical microbiology. It contained a poxvirus laboratory, and within that a small room, 8ft square, with a sealed window and a freezer stocked with vials of variola major virus, the cause of the more lethal form of smallpox.
The head of department was Prof Henry Bedson, a slight and quietly spoken man in his late 40s, an international expert in animal poxviruses, and a valued member of the WHO’s smallpox eradication campaign. His laboratory was one of fewer than 20 in the world to hold stocks of the virus, including two others in the UK – Liverpool medical school and St Mary’s medical school, London.
Despite the eradication, the worry was that there could be another poxvirus ready to jump from animals to humans, and Bedson wanted to be prepared. His research was focused on finding more efficient methods of distinguishing between different kinds of smallpox, and between smallpox and the diseases that could mimic it.
On 26 May 1978, Bedson drove to London to visit Prof Keith Dumbell, a smallpox expert at St Mary’s medical school. Dumbell handed over some vials of smallpox virus. They included an exceptionally virulent strain, isolated in 1970 from two Pakistani patients – a three-year-old boy called Abid and an 18-year-old man called Taj. Bedson drove the virus 120 miles back to Birmingham. The laboratory started work on the Abid strain in mid-July.
August 1978 was a busy time in East Birmingham hospital. Four patients were in intensive care suffering from botulism poisoning after eating salmon sandwiches, and there was a shortage of nurses.
“We’d also had a hepatitis outbreak traced to an acupuncturist the year before,” says Linda Sutherland, then a sister in one of the four infectious diseases wards. Sutherland, now 66 and living in Worcestershire, had always wanted to be a nurse. Her father’s sisters were nurses, and they had ended up working in China and India.
As soon as she was old enough, she enrolled at the South Edinburgh School of Nursing, where she found her specialism: infectious diseases. “It’s like unravelling a mystery,” she says. “Where have they been, what have they been doing?” Even today, she is very attuned to the spread of disease and likes windows to be kept open. “It’s a family joke. My sons grew up freezing cold.”
In 1977, aged 24, Sutherland moved to East Birmingham hospital. She wanted to study infectious diseases in more depth. Within a year, she was promoted to sister.
On 24 August 1978, unbeknown to Sutherland, there was an emergency admission to the hospital. At 3pm, Parker was wheeled into an isolation cubicle in ward 32 of the infectious diseases unit. By now, she was in the second week of her illness, and had spent the previous three days at her parents’ house. Her rash was getting worse, and she had been prescribed a sedative.
The doctors were puzzled. Parker had a temperature of 38C, complained of aching limbs, and had pustular eruptions all over her body. But as newspapers had announced the last known case of the disease a year before, smallpox was the last thing on anyone’s minds. Parker hadn’t been out of the country, and had been vaccinated against the disease in 1966. But as they noted her raised white cell count and mild renal failure, a terrifying realisation took hold: they had a case of one the world’s most dangerous and contagious diseases in a busy hospital in suburban Birmingham.
Alasdair Geddes, a consultant in infectious diseases, arrived at Parker’s bedside around 8pm. He took samples from three of her spots and drove to the medical school, where he met Bedson. Earlier that evening, Geddes had called him, saying: “I have a suspected smallpox here, Henry, and it’s a lady who works as a photographer in the medical school.” Geddes knew Bedson was working on smallpox in the same wing. The line went quiet.
At about 10pm, Bedson fed the samples into an electron microscope. To his horror, he saw the telltale brick-shaped particles, which could mean only one thing.
Dr Surinder Bakhshi was at home in Gloucester when he received the call to say that smallpox had arrived in Birmingham. Bakhshi grew up among the Indian Sikh community in Dar es Salaam, in east Africa. After studying medicine in Kampala, Uganda, he worked as a medical officer in Zambia, before moving to the US to do a master’s in public health. He moved to the UK in 1974.
Amiable and ambitious, at 37, Bakhshi had landed the job of medical officer for environmental health in Birmingham. No one thought he would get the job, least of all him. “I had the qualifications, but as an immigrant you’ve always got to start at the bottom,” he says, when we meet at his home in Birmingham. “When I started work, people wouldn’t speak to me – not even my secretary, for a couple of weeks. I used to tell my wife, ‘I feel very sorry for them – they look at me and feel unhappy.’”
Barely eight months later, Bakhshi was faced with the task of saving Britain’s second largest city from smallpox. At 10am the day after he got the call, he met his boss, William Nicol, Birmingham’s area medical officer, and other members of a hastily set up advisory committee, including Bedson and Geddes, as well as medical experts from national and international organisations. The committee would meet every day until 16 September.
They set up a smallpox control centre in the basement offices of Birmingham city council, with satellite centres at the medical school and hospital. Bakhshi was responsible for containing the virus in the community. The strategy was clear from the outset: trace and quarantine contacts; smallpox jabs for those who hadn’t been recently vaccinated; an antibody injection for the most vulnerable; and an antiviral drug for those directly exposed to the disease. “Contact tracing and containment are in the genes of any public health doctor,” Bakhshi says now.
Even so, systematically searching for contacts across the city, who were then instructed to isolate in their homes, was a complex operation. Bakhshi’s first achievement was to secure an unlimited budget from the local authority (the response would go on to cost more than £200,000).
He requisitioned three floors of the Holiday Inn for staff to rest. He booked cabs, so that they could get around and home safely: “I made a rule that no woman should travel alone after 6pm.” And he paid for three restaurants to supply meals around the clock. “In every outbreak I have dealt with, the first thing that comes to my mind is, where’s the food?” (Bakhshi applies the same principle to our between-lockdowns interview, cooking me a lunch of chickpea curry and basmati rice, followed by rice pudding and clotted cream ice-cream, despite being 83 and living alone.)
News of the outbreak first hit the headlines on 26 August. There was widespread anxiety and fear. The health secretary launched an inquiry into the “tragic occurrence” in Birmingham, to be led by Prof Reginald Shooter, a bacteriologist. Parliament debated the issue of dangerous pathogens leaking from laboratories.
“On the second day, the deputy chief medical officer came up from London and said, ‘This is a national emergency, do you think you can manage it?’” remembers Bakhshi. “Then he apologised and said, ‘Go ahead, it’s your responsibility. But let me know if you need anything.’”
In the control centre, 25 phone lines were staffed around the clock. “Mothers would ring at 2am or 3am: ‘My kid has a rash.’ And we would respond immediately.” Mass vaccination was not considered necessary, but as the news had broken over the bank holiday weekend, there was a rush for jabs for those travelling abroad. (By 1 September, 10 countries would be demanding holidaymakers from Britain have a vaccination before they could enter.)
Within 24 hours, most of Parker’s principal contacts had been tracked down, including two people from the medical school who were by then in the US and Germany. Reg Wickett, then 53, a hospital engineer who had been working in a ward close to Parker, had to cut short his holiday in Dorset. Cathy Hyde, 22, a physiotherapist, had to cancel her wedding and go into quarantine. Bakhshi knew there could be many more out there.
He consulted the government’s Memorandum On The Control Of Outbreaks Of Smallpox. It categorised contacts into those who had been close to the infected person (A); and those who had been in the infected place (B). Bakhshi and his colleagues subdivided category A into “close” and “remote” contacts. Close included family, friends, colleagues, neighbours, the three GPs who treated Parker before she got to hospital, and hospital staff who’d had face-to-face contact with her, including the ambulance crew. Anyone who had visited the infectious diseases unit on the day Parker was admitted, or been near her home, including refuse collectors, people delivering newspapers and milk, and journalists, were defined as “remote” contacts.
Close contacts were checked daily for symptoms, and had to quarantine at home for 16 days, followed by surveillance for four days. Remote contacts were also placed under surveillance. Bakhshi received reports from the police and neighbours complaining about people breaking quarantine. “You took it for granted it would happen. You thought, out of 100 people, I’ll win the confidence of 97. Three won’t do it. You accepted it. You had to.”
Ward 31 of East Birmingham hospital was used to quarantine hospital staff, including 10 doctors, 35 nurses, porters, engineers, a clergymen and a paperboy. By the end of the outbreak, 1,820 contacts at East Birmingham hospital had been vaccinated.
Four teams of doctors and nurses looked after category A contacts; health visitors looked after category B. Everyone in quarantine had their rubbish collected, food and newspapers delivered. “People could just ring and say, ‘I need nappies!’ And we’d drop them off, anything,” Bakhshi says. Those who lost wages were eventually compensated by a government scheme administered by the city council.
In all, around 60 doctors, 40 nurses (including 20 health visitors), 85 environmental health inspectors and staff, six disinfection officers and 90 administrators, clerical and support staff helped to contain the outbreak. Unlike today’s outsourced NHS test-and-trace system, Bakhshi’s approach was locally led and personal: “Every person was visited. We didn’t tell anyone by phone.”
On Friday 25 August, Parker’s friend Glenda Miller was in the anatomy department when she learned what was really wrong with her colleague. She remembers a feeling of disbelief. “It’s going to take her a long time to get over this,” she thought.
Miller and her colleagues were told to assemble in the bay used by the coffee club. “We had to make two lines, and they vaccinated us. Bedson vaccinated me.” She was about to walk into the shopping centre in her lunch hour when she stopped. “I thought, this isn’t right. I shouldn’t be walking around Birmingham. It was such a weird, surreal situation. So I turned around and came back.”
That evening, Miller and her husband, David, were in their back garden when her neighbour appeared over the fence. “There’s somebody at the front door wearing a turban,” she said. It was Bakhshi. “He came in looking drained and exhausted,” Miller says. He told Miller she had to stay in the house for six days and then gave her an antibody injection and a shot of the antiviral drug. “I was violently sick all night. Later they vaccinated David and my son.” Miller was visited by a doctor every day. “You had to strip off to be examined for spots, while the [doctor’s] driver turned his back.”
Meanwhile, late on the night of 24 August, an ambulance pulled into Catherine-de-Barnes isolation hospital in a village on the edge of Solihull. Catherine-de-Barnes was an eerie place, set in 25 acres down a winding lane, with a series of deserted one-storey buildings and rows of empty hospital beds. Opened in 1910, when diphtheria, typhoid and smallpox were rife, Catherine-de-Barnes was still on standby in 1978. Its resident caretakers, Leslie and Dorothy Harris, had been there for 11 years without ever admitting a patient. Then Janet Parker arrived.
As Parker’s nurse, Linda Sutherland should have arrived that night, too, but she was with her new boyfriend and husband-to-be, Stan, a senior house officer at the hospital. When she returned to her flat mid-morning, she was greeted by a note from her flatmate: “Urgent, call the nursing officer.” “Well, that’s me rumbled,” she thought. “Everyone’s going to know I haven’t slept in my own bed!”
A year earlier, Sutherland had added her name to a list of infectious disease nurses who were willing to be confined with a patient in isolation. It appealed to her sense of adventure. “What kind of exciting case would I meet?” she thought. “Never in a million years did I think of smallpox.” She was told to pack a bag and wait for a taxi.
When Sutherland first met Parker, she was sitting up in bed with a copy of Woman’s Own and a radio on her bedside table. She had an entire ward to herself, and lay surrounded by rows of empty iron hospital beds. The nurses’ digs were across the courtyard, and Sutherland and Mary Neary, an older ward sister, were soon joined by Deborah Symmons, a junior doctor in the infectious diseases unit at East Birmingham hospital. Hugh Morgan, professor of tropical medicine at the hospital, dropped in daily. Sutherland still wonders why he was allowed to go home.
Sutherland and Neary decided on “factory shifts” – eight hours on, eight hours off, throughout the day and night. “It was dreadfully draining,” she says. Her PPE was a white cotton gown, cotton mask, theatre-style cap and disposable gloves. “It was pretty basic. But that was what was available.”
It was later confirmed that Parker had most likely been infected by the Abid strain of the virus. She was weak by now, and couldn’t change her nightgown, blow her nose or clean her teeth without assistance. Sutherland would bathe her and apply antiseptic, gently taking Parker’s arms and legs in her hands, soothing her angry skin. She ordered a blow-up “ripple bed” to ease the pressure on her raw body, and gave her Bonjela for the sores in her mouth. “Totally inadequate, but what we had at the time,” she says. They tried to coax Parker to eat “soft food”: soup, macaroni cheese, jelly and ice-cream.
By the end of the first week, the spot over Parker’s right eye had ruptured, making it hard for her to read. Her hair would get stuck in the gunked-up sores on her shoulder blades. Parker had a mirror, and would use it to scrutinise her face. She would look at her arms and the palms of her hands, taking in the full horror.
“I think she was really distressed by it all,” says Sutherland. “Some people can be ill, but they are so out of it, they are oblivious a lot of the time. Janet wasn’t like that. She was aware, and that must have been horrible.” Once, Sutherland saw tears creep down her inflamed cheeks.
On Tuesday 29 August, Parker’s neighbour was admitted to Catherine-de-Barnes, but discharged the next day after being given the all clear. More patients arrived – nine, in all – but in most cases the diagnosis was a reaction to the vaccine. More nurses were deployed, including staff to look after Parker at night, while Sutherland and Neary continued to take charge during the day.
On Sunday 3 September, Fred Whitcomb, Parker’s 71-year-old father, woke up at home with slight nausea and was admitted as a precaution to the male ward across the corridor. The next day he died of a suspected heart attack, brought on, according to one press report, “by the stress of the situation”.
On Wednesday, Sutherland heard another piece of terrible news. Henry Bedson had killed himself. As soon as smallpox had been confirmed, rumours began to circulate in the press that Bedson’s lab was to blame. Quarantined at home with his wife and their three children, he looked out at the journalists camped outside his front door and felt the hot glare of judgment. Bedson left a suicide note in his shed apologising for “the misplaced trust which so many of my friends and colleagues have placed in me and my work”.
Over the following days, Parker grew weaker. By the third week in hospital, she had lost the sight in both eyes, developed pneumonia, and her face was caked with scabs. Sensing the end was near, the nurses called Parker’s husband, asking if he’d like to come in. He said no – it would upset her too much. “Perhaps it would have upset him, too,” says Sutherland. “I remember thinking, that’s going to be the last picture he has of her, and that’s a terrible picture to carry.”
Parker died on Monday 11 September, at 3.50am, the last recorded person to die of the disease anywhere in the world. When Sutherland was told the following morning, she was given a cup of Irish tea, with a glug of whiskey. “I was really upset,” she says. “I don’t know if I cried in front of anyone. Probably not. It would have been frowned on.”
But Parker was not to be the last case of smallpox. On 7 September, her mother had been admitted with a rash that was thought to be vaccine-related. It was in fact smallpox. Hilda was in Catherine-de-Barnes when her husband and then her daughter died, but couldn’t see either of them. Nor was she allowed to attend their funerals. Unmarked police cars escorted the funeral cortege when Janet’s body was taken to the Robin Hood crematorium in Solihull, in case of an accident. All other funerals were cancelled that day, and the crematorium was deep-cleaned afterwards.
Hilda was discharged on 22 September, after a mild case of the disease, owing, it is thought, to the protective action of the vaccination she’d had after her daughter was diagnosed (she had also been vaccinated as a child), as well as the antiviral drug. She was the only other person infected in the Birmingham outbreak.
“I still think about her mum a lot,” says Sutherland. “How did she manage?”
How did Janet Parker come to be infected with smallpox? The Shooter report – the official government inquiry, published in December 1978 – put forward the “pox-in-the-ducts” theory. It concluded that the virus had been carried through air ducts from the smallpox lab into the enclosed courtyard outside, where it drifted up to the photography department on the first floor, and through an open window into the telephone room. Records showed that Parker had made a number of calls on 25 July, just as the Abid strain was being handled on the floor below.
The theory was largely discredited in the legal case the Health and Safety Executive brought against the University of Birmingham in 1979. An expert witness said the hypothesis was “highly implausible”, as the amount of virus dispersed from an airborne droplet would have been minute, particularly as the laboratory was working on diluted material.
Brian Escott-Cox was the barrister who won the case for the university. Now 88, he still has the slicked-back hair and sonorous voice of a QC. He knew Parker through his work in the 60s and 70s, when she was still photographing crime scenes. He remembers being impressed by her professionalism, but mostly by the fact that she was there at all. “Law was still a man’s world,” he says, as was the police.
“It was gut-wrenching when I realised it was the Janet who used to come to court as a police photographer,” he says. “For her to die at 40, even if she’d been run over by a bus, would have been a tragedy. But for her to die in awful, agonised, humiliating circumstances is cruel beyond description,” he swallows hard, his eyes filling with tears.
So what did actually happen? Mark Pallen suggests in his book that if the virus did not “go” to Parker, she must have “gone” to the virus. Escott-Cox has a theory as to why. In 1966, Tony McLennan, then 23, worked as a photographer in the medical school. Like Parker, 12 years later, he caught smallpox. Unlike Parker, his case was mild. What a strange coincidence, points out Escott-Cox, “that the only people who ever caught smallpox didn’t work in the lab, and were photographers”.
He believes McLennan either took over or started the practice of visiting all the departments in the medical school, knocking on doors, asking people before they went on holiday if they wanted any photographic film or other materials. Perhaps he made a small mark-up, or perhaps it was a favour.
“By the time Janet got there, it had become an institution, and I strongly believe this was the fateful moment of contact,” Escott-Cox, continues. “If you’re collecting orders, you’re going to write it down, or somebody is going to hand you a list. Janet had no idea that a particularly virile strain had recently arrived in the lab. It would never have crossed her mind she was putting herself in danger.”
There is no evidence that procedures in Bedson’s lab had been lax. The WHO had visited in May 1978, and raised only minor concerns, such as the lack of showers or absence of containment in the outer room. A new, purpose-built pox lab would have been better, but everyone had agreed that work on smallpox was drawing to a close.
After the outbreak, says Sutherland: “We were told, very firmly, not to speak about it by hospital authorities.” So, she didn’t, until recently. “Which I suspect didn’t help in psychological terms.” She now thinks she probably had post-traumatic stress disorder. “There is one picture in my head, and I wish it wasn’t there. It was a total invasion of her and you were just helpless.” Her husband, Stan, said she was never the same again. Sutherland left nursing in 1980 to become a health visitor, and had two sons. She went on to work as a counsellor, and is now retired. She and Stan separated 23 years ago.
Miller was transferred from anatomy to the biochemistry department on the advice of her union. “There were safety concerns,” she says. She left the medical school a year later to have her second child, and went into teaching.
Bakhshi suffered from depression about six months after the outbreak ended. “It must have affected me,” he says. “But there were no counsellors then. You put it to one side.” The low mood lasted for a couple of years. He retired aged 65.
Birmingham was officially declared free of smallpox on 16 October 1978. The containment had been a huge success: a city had been saved from waves of devastation. “The local authority had vast resources,” says Bakhshi. He had been allowed to make his own decisions, by a government that enabled a local and personal response. “And this is relevant with what is happening now,” he adds. “There was never a fear of who was going to do the job. I had to win the trust of the people. You can have algorithms, data analysis, this, that. But at the end of the day, you can’t put someone in quarantine unless they trust you.”